When the first shipments of the Pfizer-BioNtech Covid-19 vaccine arrived in Singapore, Minister Ong Ye Kung welcomed it together with a contingent of journalists at Changi Airport.
Similarly, when the Moderna Covid-19 vaccine arrived in February, Prime Minister Lee Hsien Loong said on Facebook that he was “pleased” with its “safe arrival”.
In March, the Chinese Embassy in Singapore announced the arrival of 200,000 Sinovac vaccine doses. This time around, there were no reassuring messages from government officials or photo opportunities at the airport. In fact, the Chinese Embassy made the announcement first, even before Singapore’s Ministry of Health acknowledged the shipment.
The vaccines sat in a storage facility, unused for months. Things only changed in May, when the Singaporean government announced that it would be allowing private healthcare providers to tap on the country’s Sinovac stockpile. Interestingly, unlike the Moderna and Pfizer shots, the Sinovac vaccine was approved under a Special Access Route (S.A.R.).
But what exactly does this mean? Why aren’t Sinovac vaccines part of the national vaccination campaign? These are the questions that we answer in today’s explained.
Does the Sinovac vaccine work?
CoronaVac’s (the name of the Sinovac vaccine) efficacy has been a source of extreme debate around the world. Studies on the vaccine has led to vastly differing results on its efficacy. A Phase III clinical trial from Brazil showed that the shot was only 50.7% effective in preventing symptomatic infections. This is also the final efficacy rate that the World Health Organisation (W.H.O.) adopted. On the other hand, real world data from Indonesian healthcare workers showed 94% protection against symptomatic infection.
So what explains these differing results?
Well, unlike the Moderna and Pfizer-BioNTech clinical trials, which were centralised and directed by the respective companies, Chinese vaccine producers left trial protocols to each country’s discretion. This meant that each study of the vaccine had very different scopes, volunteer profiles, testing and case definitions. Due to this, safety data is currently limited for people above 60 years of age (since there was a small number of participants in clinical trials).
Furthermore, there have been accusations of a lack of transparency on the part of Sinovac. Usually, vaccine manufacturers like Pfizer and Moderna release details of their final stage clinical trials in peer-reviewed journals. Publication in peer reviewed journals matter as they would reveal the underlying data behind the results and would require vetting by third-party experts. Sinovac has yet to do this and has opted to self-report key results from the study instead.
To make matters worse, concerns over the vaccine’s efficacy against more infectious variants have intensified over the last weeks. The much heralded 94% efficacy rate in Indonesia has come into question, since more than 350 medical workers have caught Covid-19 despite being vaccinated. Dozens of these healthcare workers have also been hospitalised. A major study by the University of Hong Kong found that people vaccinated with Pfizer-BioNTech jabs had “substantially higher” levels of antibodies as compared those who received the Sinovac vaccine.
In all, CoronaVac seems to be less efficacious than the Moderna and Pfizer vaccines. However, most of the studies done on the Chinese jab also showed that it was highly effective in preventing severe cases of Covid-19 and death. This is exactly why CoronaVac remains attractive to developing countries. While the more efficacious vaccines have been hoarded by developed countries, in poorer regions, some protection is better than no protection at all. It is hoped that a reduction in hospitalisation rates would ease the strain on already buckling healthcare systems.
Why does Singapore allow Sinovac to be administered?
Unlike these developing countries, Singapore seems to have secured enough Moderna and Pfizer doses for its entire population. As early as summer 2020, officials from the city-state had placed advanced orders with both pharmaceutical companies. Moderna’s Chief Executive Officer, Stephane Bancel, had even remarked in an interview that Singapore was in the “leading front of acting early… and deciding to place orders” for these more effective vaccines.
This leads to questions about why Singapore is allowing for the administration of less efficacious vaccines in the first place. According to analysts, part of the reason might be attributed to diplomacy.
To China, global acceptance of its vaccines are an important policy end-goal. It helps redirect anger and criticism over the country’s early handling of the pandemic, paint the country as a global leader in science and technology, and gain influence in the developing world. Also, as China continues to ramp up its vaccination campaign domestically, international adoption might lead to higher acceptance amongst Chinese citizens.
Being the only developed country that has bought doses of Sinovac, Singapore serves to be an important showcase for Chinese vaccines. This is particularly the case, considering the country’s reputation for high standards. Chong Ja Ian, a political scientist at the National University of Singapore, said in an interview that a Singaporean authorisation of Sinovac would be seen as a “seal of approval” for all Chinese developed vaccines.
In addition to this, Singapore has other incentives to adopt Chinese vaccines. While neutrality isn’t enshrined as a principle of foreign policy in Singapore, the island-state has practiced de facto even-handedness when dealing with great powers. Any setting which could be seen as a battleground for superpower relations is handled delicately to avoid accusations of side-taking. This is why, for example, the country refused to officially ban Huawei bids for its 5G networks despite U.S. pressure.
The reality is that China is the island’s biggest trading partner, while the U.S. is the most important military and strategic partner. It is this careful balance of power that Singaporean diplomats try to uphold.
By not buying or administrating Chinese vaccines, Singapore might risk upsetting Beijing by not considering its interests. At the same time, adopting Sinovac on a large scale might be a bad public health decision, considering its low efficacy.
How should the government respond to these pressures?
Whether it was intentional or not, approving the Sinovac vaccine through the Special Access Route (S.A.R.) helps resolve these opposing pressures. The S.A.R. allows private healthcare clinics to bring in Covid-19 vaccines that have been approved by the World Health Organisation. This works to solve the tension between public health and diplomatic goals on three levels.
- The costs of getting a Sinovac jab are made higher
On the first level, unlike the Moderna and Pfizer-BioNTech vaccines, Sinovac jabs are not part of the universal and free national vaccination campaign. In order to a get Sinovac jab, you would have to pay between $10 to $25 per dose at a private healthcare institution. While the government provides the vaccines to the clinics for free, the clinics were allowed to charge a vaccination administration fee, which is inclusive of consultation and a 7% goods and services tax.
Also, since the China-made vaccine is not part of the national program, those who opt for it will not be eligible for the government’s Vaccine Injury Financial Assistance Programme (Vifap) if they develop adverse reactions. By making the costs – both present and potentially future – higher, there is a financial disincentive for people to take these Sinovac vaccines.
- The Sinovac vaccines seem to be more inaccessible
Originally, it was reported that 5 large healthcare groups – Farrer Park Hospital, Fullerton Health, Raffles Medical Group, Thomson Medical and IHH Healthcare Singapore – applied to offer the Sinovac Covid-19 vaccine. On June 17, however, the government announced a list of 24 smaller clinics that were selected to administer the Sinovac jabs. None of the five large healthcare groups were on the list.
The clinics that were indeed on the list, also seemed to receive a relatively low amount of doses from the Ministry of Health (M.O.H.). For many private clinics, the first shipment of Sinovac from M.O.H. only consisted of 200 doses of vaccines. One clinic also reported that there was a hard cap on the number of doses that each clinic could receive. StarMed Specialist Centre, a clinic in Farrer Park, was only allowed to order 1,000 doses of the vaccine altogether.
All of this might potentially reduce the number of people who opt to get Sinovac jabs, thereby reducing the amount of potential breakthrough infections.
- Sinovac vaccines have not been given interim authorisation
It is also important to note that the Health Science Authority (H.S.A.) has not officially authorised the CoronaVac. While the Moderna and Pfizer shots were given interim authorisation by the agency, Sinovac shots have only been allowed for use through the Special Access Route. According to the government, CoronaVac was not given this interim authorisation as the company did not provide the needed data “to help in the process of evaluation”.
Though the S.A.R. allows for allows private clinics to bring in W.H.O. approved vaccines, it does not authorise and thereby tacitly endorse the safety and efficacy of the vaccines. It also ensures that the H.S.A. does not need to lower its standards, in order to let Sinovac be administered in Singapore.
Why was there overwhelming demand for the Sinovac jab?
On June 17, a day after the M.O.H. released its list of Sinovac approved clinics, hundreds of predominately middle-aged Chinese Singaporeans queued in order to get their names in waiting lists for the Chinese jab. According to both ChannelNewsAsia and Today, the response was overwhelming for the Sinovac vaccine.
“We feel like the Indonesian McDonald’s that opened up for BTS army orders for the latest promotion”, said Dr Leong Hoe Nam, an infectious disease specialist at Rophi Clinic, to Today. The clinic also had a waiting list that exceeded 700 people by 3.40pm on the same day.
On a surface level, this doesn’t quite make sense. Why would Singaporeans, who have sufficient access to more efficacious vaccines, line up in order to get a jab that might not be as effective?
Part of the answer has to do with misinformation.
As early as January 2021, Chinese state media outlets ran articles criticising Western Covid-19 vaccines, while touting China-made vaccines as being safe. There were allegations of the west “deliberately downplaying” vaccine related deaths and also unsubstantiated claims about Chinese vaccines being safer “due to their mature technology”. The Global Times, for example, accused the U.S. and the U.K. of “using propaganda power to promote the Pfizer vaccine and smearing Chinese vaccines”. These claims are largely false and have been rebutted by scientists and public health officials alike.
Interestingly, however, the very same talking points have made their way to Singapore in the lead up to the approval of the Sinovac jab. Mothership, for example, reported that there had been messages circulating on WhatsApp that had criticised Singapore’s decision to exclude Sinovac from the country’s national vaccination programme.
In one particular video, a man who appeared to be a Chinese national parroted talking points from Chinese ultra-nationalists and state media. The line of logic was eerily similar to the misinformation from January: foreigners did not want to see China’s rise, and as such were smearing Chinese vaccines while promoting western ones.
Interviews of those who waited in line for the Sinovac shot also seemed to reflect this proliferation of misinformation. “I have more faith in the old system of inactivated virus. I believe in the real world results instead of the scientific trials and peer reviews,” said one elderly Chinese man to The Straits Times. Yet again, the sentiments seem similar to the misinformation that was posted by Chinese and Russian linked social media accounts earlier in the year.
While the government has started to respond to some of these claims on its official website, questions remain about how best to deal with misinformation. It’s an issue that most countries with high internet penetration rates face, and Singapore does not seem to be immune to it. Nonetheless, it is an important issue to resolve, considering that misinformation in cases such as these might literally lead to life-and-death outcomes.